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What is venous insufficiency?

Inadequate venous drainage of the lower extremities


What causes venous insufficiency?

- Clot
- Inherited abnormality of the veins
- Increased pressure in the venous system (mechanical or metabolic)


What is superficial venous insufficiency called?

Varicose veins


What is deep venous insufficiency called?

Chronic venous insufficiency


What is a thrombus?

Presence of a clot


What is phlebitis?

Inflammation within a vien


What is thrombophlebitis?

A broad term for inflammation of a view with or without the presence of a clot


What vein is most commonly involved in a superficial thrombophlebitis?

Great saphenous vein

This is more common than the lesser saphenous vein


How common is superficial thrombophlebitis?

3-11% of the general population


What are the risk factors associated with superficial thrombophlebitis?

Associated with conditions that increase the risk of thrombosis
- Coagulation abnormalities
- Endothelial dysfunction
- Venous therapy (following vein ablation)
- Malignancy and hypercoagulable states


What is the patient presentation of a superficial phlebitis?

- Tenderness, induration, pain and erythema along course of superficial vein, palpable cord***


What should you be thinking if a pateint presents like this?

High index of suspicion for DVT in patients with risk factors (such as a previous DVT)


How do you treat a superficial thrombophlebitis?

- Treatment is aimed at alleviating symptoms such as pain and swelling (NSAIDs, warm compression, elevation)
- Thrombus PREVENTION in deep veins
- Coagulation in patients with extensive involvement or high risk patients


What is one type of superficial venous insufficiency?

Varicose veins


Describe varicose veins

- Dilated, elongated tortuous
- Involves superficial veins 3 mm or greater is size
- Effects 10-30% of the population
- Seen more often in older patients


What is the pathology behind varicose veins?

- Inadequate muscle pump
- Incompetent valves leading to reflux
- Venous obstruction


What do the pathological aspects of varicose veins lead to?

Increased venous pressure - known also as "venous hypertension"

- Venous hypertension --> vein dilation --> skin changes ---> skin ulceration


Describe the effect of incompetent valves

Valves become incompetent, veins are permeable  the fluid in the blood leaks out and produces edema and fluid accumulation


How do you diagnose varicose veins?

- Diagnosis correlates with the degree of venous "reflux"
- It is identified by venous duplex ultrasound as retrograde (reversed) flow of greater than 0.5 seconds in duration


How do you manage varicose veins?

You treat according to the severity and etiology of the underlying reflux
- Conservative treatment includes elevaion, compression and exercise
- Invasive treatment is ablation therapy


What is chronic venous insufficiency again?

The presence of thrombophlebitis in a deep vein
- The chronic insufficiency is associated with structural and histological changes


What structural and histological changes occur in chronic venous insufficiency?

- Capillary microcirculatory disorders
- Fibrin deposition
- Inflammation


What do these histological changes lead to?

- All of the histological and structural changes lead to impaired oxygenation of the skin and subcutaneous tissue
- This results in edema, hyperpigmentation, fibrosis (feels like elephant skin) and ulcer formation



How can you differentiate between an infection and chronic venous insufficiency?

Bilateral usually means it is chronic venous insufficiency rather than an infection


What are the treatment goals for chronic venous insufficiency?

- Improve symptoms
- Reduce lower extremity edema
- Healing and prevention of ulcers


How do you reach these goals?

- Leg elevation
- Exercise
- Compression therapy
- Skin care


Describe leg elevation

- Level of heart or above 30 minutes 3-4 times/day
- Helps to improve microcirculation and reduce edema


Describe exercise

Walking or ankle flexion exercise to help with muscle pump


Describe compression therapy

Choice of compression varies from patient to patient


Describe skin care

- Emollients to lubricate dry skin
- Be kind of careful, don’t get too much lubrication, it will cause it’s own ulcer